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An Introduction to Geriatrics-Competent Care · 20/8/2014 · This webinar is supported through...
Transcript of An Introduction to Geriatrics-Competent Care · 20/8/2014 · This webinar is supported through...
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Geriatrics-Competent Care
Webinar Series
An Introduction to
Geriatrics-Competent Care
August 20, 2014
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Introduction to
Geriatrics-Competent Care
A Discussion of Universal Competencies that are Fundamental to Quality
Geriatrics Care, Across Disciplines and Care Settings
This webinar is supported through the Medicare-Medicaid Coordination Office (MMCO) in the Centers for Medicare & Medicaid Services (CMS) to ensure beneficiaries
enrolled in Medicare and Medicaid have access to seamless, high-quality health care that includes the full range of covered services in both programs. To support providers in their efforts to deliver more integrated, coordinated care to Medicare-Medicaid enrollees, MMCO is developing technical assistance and actionable tools based on successful innovations and care models, such as this webinar series. To learn more about current efforts and resources, visit Resources for Integrated Care
(www.resourcesforintegratedcare.com) for more details.
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Platform Overview
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■ This is the first session of a two-part webinar series titled "Geriatrics-Competent Care.”
■ Each session will be interactive (e.g., polls and interactive chat functions), with 60 minutes of presenter-led discussion, followed by 15 minutes of presenter and participant discussions.
■ Video replay and slide presentation will be available after each session at: www.resourcesforintegratedcare.com
Overview
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■ Gregg Warshaw, Moderator Martha Betty Semmons Professor of Geriatric Medicine
Professor of Family and Community Medicine
University of Cincinnati College of Medicine
■ Kyle Allen Vice President for Clinical Integration
Medical Director, Geriatric Medicine and Lifelong Health
Riverside Health System
■ W. June Simmons President/CEO
Partners in Care Foundation
Introductions
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What’s Unique About Older Adult Care
Prevention
Risk of Care Transitions
Safe Medication Use for Older Adults
Understanding Geriatric Syndromes
Social Services and Supports in Geriatrics-Competent Care
Topics Covered
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Getting to Know Our Audience
Poll Question #1 – Which of the following best describes your professional area? ■ Healthcare Administration ■ Medicine/Nursing/Physician Assistant ■ Pharmacy ■ Social Work
■ Advocacy ■ Other
Poll Question #2 – What is your primary role? Administrator Clinician Educator Researcher Consumer Advocate Other
Poll Question #3 -- In what setting do you work? ■ Community Health Center / Federally
Qualified Health Center ■ Home Care ■ Long-term Care Facility ■ Managed Care Organization
■ Consumer Organization ■ Other
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What’s Unique About Older Adult Care?
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There is considerable diversity among older adults:
Physiological
Functional
Cultural
Individualized care, rather than protocol-based care, is especially important for older people.
Diversity Among Older Adults
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■ is not a disease
■ occurs at different rates
among individuals
within individuals
■ does not generally cause symptoms
Aging
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The Rule of Fourths
Of the “decline in
normal function” seen as people age…
Disease 1/4 is due to
Dis-use
Physiological aging
1/4 is due to
1/4 is due to
1/4 is due to
Misuse
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■ An 83-year-old woman comes to the office for an examination. She has recently returned to her home after a motor vehicle accident that resulted in injuries, a hospital stay complicated by pneumonia, and a nursing-home stay.
■ She is greatly changed since her last office visit: she has lost a lot of weight, moves slowly, and is unable to rise from her chair without using her arms.
■ She previously was an avid golfer and swimmer. She asks what she can do to improve her function now that her injuries have healed.
Case Study
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Case Study
Which of the following is effective in improving function in frail older adults?
A. Comprehensive geriatric assessment
B. Protein supplementation
C. Anabolic steroids (testosterone, dehydroepiandrosterone)
D. Exercise
E. Home visits to evaluate function in the home function in the home
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■ Function, not diagnosis, is what counts, as multiple chronic diseases are common.
■ It is important to identify functional deficits that adversely affect the person’s prognosis and quality of life.
Function: The Critical Outcome
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Principles of Geriatric Assessment
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Goal: Promote wellness, independence Focus: Function, performance (gait, balance, transfers) Scope: Physical, cognitive, psychological, social domains Approach: Multidisciplinary Efficiency: Ability to perform rapid screens to identify target areas Success: Maintaining or improving quality of life
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Working with the older adult and their family to determine, based on the patient’s goals of care:
The right amount of care (not too much, not too little)
In the right location (least intensive is usually best)
Care Planning
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■ In geriatric care, acting hastily is more likely to do harm than not acting at all.
■ Care decisions need to be paced so that the patient, the family, and the clinician have time to evaluate options before proceeding.
Slow Medicine
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Inter-professional team care is essential to providing optimal care for older adults.
Team Care
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Prevention
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■ Immunizations and screening tests that are recommended for older adults based on their remaining life expectancy and cognitive status.
■ Additional preventive activities and services that are potentially beneficial for older adults.
Prevention
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■ Frail older adults have limited physiologic reserve.
■ Illness caused by medical interventions is one of the most common yet preventable medical problems of older people.
■ The risk/benefit of diagnostic tests and treatments must be reviewed carefully in order to avoid iatrogenic illness.
Iatrogenic Illness
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■ Emphasize advantages: promotes mobility, rates of heart disease & osteoporosis
■ Recommend a program that balances exercise for:
Flexibility (e.g., stretching)
Endurance (e.g., walking, cycling)
Strength (e.g., weight training)
Balance (e.g., Tai Chi, dance)
Physical Activity
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■ New Medicare benefit created by the Affordable Care Act
■ Designed to address: geriatric assessment
medication management
Injury prevention
Annual Wellness Exam
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Risk of Care Transitions
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Transitions of care from one provider or setting to another can lead to:
misunderstandings of diagnoses and plans
medication discrepancies
confusion on the part of patients and families
Many older adults have limited physiologic reserves and at are at risk of bad outcomes during poorly handled transitions.
Care Transitions
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Emergency department visit
Inpatient hospitalization
Operating room Intensive care unit Ward
Skilled-nursing
facility
Home with or
without home-
health care
Nursing or
rehabilitation facility
Specialists Primary care provider
Common Care Transitions
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Safe Medication Use for Older Adults
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Effective drug treatments for chronic illnesses have expanded, and many older people have multiple chronic illnesses.
Adverse drug reactions and drug-drug/drug-disease interactions increase as the number of prescribed medications increases.
Adherence to complex, multiple drug regimens is difficult: poor vision, poor memory, limited funds, etc.
Medication Safety Challenges
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■ Safety and effectiveness of any given medication is not well studied in the aged.
■ Multiple concomitant medications adversely affect the safety and effectiveness of individual medications.
■ Multiple medical problems can adversely affect the outcomes of pharmacotherapy.
Gaps in Our Understanding of Medication
Use in Older Adults
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■ One clinician on the patient’s health care team must take responsibility for all the medications prescribed by all providers.
■ Regular review of all medications – prescribed and over-the-counter – with the goal of trying to reduce medication use as much as possible.
Major Considerations in Safe Medication
Use for Older Adults
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■ Consider non-pharmacological approaches first .
■ Start low, go slow. Evaluate thoroughly.
■ Caution with medications new to the market.
■ Annual medication reconciliation, including over-the-counter, vitamins, supplements, herbal or other remedies.
■ Keep possible medication side effects in mind at all times.
General Approaches to Medication Use
in Older Adults
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■ Is this medication necessary?
■ What are the therapeutic end points?
■ Do the benefits outweigh the risks?
■ Is it used to treat effects of another drug?
■ Could 1 drug be used to treat 2 conditions?
■ Could it interact with diseases, other drugs?
■ Does patient know what it’s for, how to take it, and what adverse side effects to look for?
Before Prescribing a New Drug,
Consider:
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Understanding Geriatric Syndromes
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■ Accumulation of multi-system deficits is responsible for the existence of geriatric syndromes.
■ Geriatric syndromes are typically multi-factorial.
■ Rare in younger people and common in older adults.
Understanding Geriatric Syndromes
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■ More than 50% of older adults have 3 or more chronic diseases.
■ Multiple chronic illnesses are associated with increased rates of death, disability, adverse effects, institutionalization, use of healthcare resources, and impaired quality of life.
■ Older adults with multiple geriatric syndromes are heterogeneous in terms of illness severity, functional status, prognosis, personal priorities, and risk of adverse events.
Understanding Geriatric Syndromes
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■ Falls
■ Gait and balance problems
■ Dizziness
■ Weakness
■ Frailty
■ Incontinence
■ Confusion
Most Significant Geriatric Syndromes
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■ Annual incidence of falls is close to 60% among those with history of falls.
■ Complications of falls are the leading cause of death from injury in people aged ≥65.
■ Most falls are not associated with syncope.
■ Falls literature usually excludes falls associated with loss of consciousness.
Falls: One of most common geriatric
syndromes
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Ask all older adults about falls in past year
Single fall: check for balance or gait disturbance
Recurrent falls or gait or balance disturbance:
Obtain relevant medical history, physical exam, cognitive and functional assessment
Determine multifactorial falls risk (see next slide)
Falls Assessment
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Factors Affecting Fall Risk
■ History of falls
■ Medications
■ Visual acuity
■ Gait, balance, and mobility
■ Muscle strength
■ Neurologic impairments
■ Heart rate and rhythm
■ Postural hypotension
■ Feet and footwear
■ Environmental hazards
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■ Most favorable results with health screening followed by targeted interventions
■ Aim to reduce intrinsic and environmental risk factors
■ Interdisciplinary approach to falls prevention is most efficacious
Falls Treatment
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Social Services and
Supports in
Geriatrics-Competent
Care
Bringing medicine,
families and
community-based services
together
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■ The focus is on modifiable risk factors at home
■ Resources available – there are many community-based agencies serving elders
■ Social workers are “eyes and ears” to identify risks and unmet needs and facilitate access to:
Social services, public benefits and home care, food, transportation and caregiver support
Evidence-based programs for individuals and caregivers aimed at enhanced self-management
Social Services and Supports in
Geriatrics-Competent Care
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Psychosocial and Environmental
Assessment
■ Functional assessment (ADL/IADL)
■ Fall risk – Medications, lighting, trip hazards
■ Screening for depression (PHQ 2/9) and cognitive impairment (Mini Mental Status)
■ Home safety/cleanliness/maintenance
■ Identification of barriers to compliance with treatment plan
■ Evidence of problems (e.g., alcohol bottles, odors, moldy food)
■ Social support & services – Both patient and formal/informal caregivers; abuse indicators
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Community Care
Coordination
Current MSSP Services Model: (can be adapted for Duals as CMS rules change)
Referred Services • AAA • IHSS • Community Based Adult
Services (formerly Adult Day Health Center)
• Regional Center • Independent Living Centers • Home Health • In-Home Palliative Care • Hospice • DME • Families / Caregivers Support
Programs • Senior Center Programs • Evidence-based Health
Impacting Self-Care programs • Long-term home-delivered
meals • Housing Options • Communication Services • Legal Services • HICAP • Ombudsman • Benefits Enrollment for services
(ie food stamps) • Money management • Transportation • Utilities • Volunteer services
Purchased Services (Credentialed Vendors) • Safety devices, e.g., grab bars, w/c
ramps, alarms • Home handyman • Emergency response systems • In-home psychotherapy • Emergency support (housing,
meals, care) • Assisted transportation • Home maker (personal care
/chore) and respite services • Replace furniture /appliances for safety/sanitary reasons • Heavy cleaning • Home-delivered meals – short
term • Medication management
(HomeMeds) • Special needs required to maintain
independence
Social Worker RN
Client &
Family
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Why Focus on Community Partnerships
for Social Services?
■ Improve health care for adults with chronic conditions through comprehensive, coordinated, and continuous expert and evidence-based services
■ Add in-home assessment/coordination of supportive social services to medical care
Enhance impact of medical care
Improve health outcomes
■ ACA and Duals plans provide opportunity for shared cost savings for LTSS
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Health Care + Social Services =
Better Health and Continued Independence
■ Identify/Address Social Determinants of Health:
Functional status, personal choices in everyday life
Isolation, family structure/issues, caregiver needs
Environment – home safety, neighborhood
Economics – affordability, access
■ Community Based Organizations have:
Time to probe, trust, different authority
Cultural/linguistic competence
Lower-cost staff & infrastructure
High-impact, evidence-based programs
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Expanding Supports for Aging Well
■ There is an expanding deployment of social workers to identify challenges and threats to aging well at home for complex patients.
■ Evidence-based community programs have been established for patient activation to address lifestyle change – especially to manage risks like diabetes progressing, heart disease and falls.
■ Pro-active care is emerging – focus on the whole person.
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Targeted Patient Population Management
with Increasing Disease/Disability
Late
Life
Complex Chronic Illnesses w/ major
impairment
Chronic Condition(s) with Mild Functional &/or
Cognitive Impairment
Chronic Condition with Mild Symptoms
Well – No Chronic Conditions or Diagnosis without Symptoms
Hot Spotters!
Evidence-Based Self-Management, Home
Assessment and HomeMeds
Home Palliative Care
Post-Acute and Long-Term Supports and Services
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Targeting for Social Services:
Focus on Concentration of Risk
■ Functional limitation
■ Dementia
■ Frailty
■ Serious illness(es)
■ Hospital/Emergency room use
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Home and Community-Based Services
are High-Value
■ Improves quality
Staying home is concordant with people’s goals
■ Reduces spending
Based on 25 state reports, costs of home and community-based LTC services less than 1/3rd the cost of nursing home care
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Services Targeted to Individual Needs
Evidence-based Self-Management
Independent w/ chronic condition
HomeMeds,
Stanford Chronic Disease Self-Management
(Diabetes, Pain, Spanish versions)
Short-term In-Home Services
At risk for deterioration & high utilization
Care transition coaching
Risk screening
Psychosocial evaluation
Service coordination
Long-term Services & Supports
Frail/disabled
Service coordination,
Purchase of services (meals, respite,
transport, chores)
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Some Evidence-Based
Programs
SELF-MANAGEMENT
■ Chronic Disease Self-Management
■ Tomando Control de su Salud
■ Chronic Pain Self-Management
■ Diabetes Self-Management Program
PHYSICAL ACTIVITY
■ Enhanced Fitness & Enhanced Wellness
■ Healthy Moves
■ Arthritis Foundation Walk With Ease Program
MEDICATION MANAGEMENT
■ HomeMeds
FALL RISK REDUCTION
■ Stepping On
■ Tai Chi Moving for Better Balance
■ Matter of Balance
DEPRESSION MANAGEMENT
■ Healthy Ideas
■ PEARLS
CAREGIVER PROGRAMS
■ Powerful Tools for Caregivers
■ Savvy Caregiver
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Home Assessment Improves
Medication Safety
■ Home visit by nurse or social worker Collect comprehensive medication information
Assess for possible adverse effects & discrepancies
Screen through software to find potential problems
■ Pharmacist review & resolve problems, educate
■ Supporting resources are valuable to assure effective use of meds gathered in home visits
■ Emerging Models: Targeted home visits for high-risk patients
Add to care transitions, self-management programs
caregiver support, etc.
Part of comprehensive fall prevention initiative
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Post-Acute Social Work Home Coaching
■ Compared to patients who met referral criteria but did not receive the home visit 12.8% lower rate of ED use
22% lower rate of readmissions
■ Medication Issues Identified and Recommendations Made by PharmD: 63%
■ Other issues identified (e.g., PHQ-9, caregiver or financial need): 54%
■ Falls risks identified – 77%
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■ Apply Principles of Geriatrics-Competent Care
■ Form Partnerships of Health Care Providers, Home and Community-Based Providers, Consumers and Advocates
To Achieve the Triple Aim: Better Care,
Better Health, Lower Cost
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Questions
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